Us Standard Certificate Of Death
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4U.S. STANDARD CERTIFICATE OF DEATH
LOCAL FILE NO.
STATE FILE NO.
1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last)
2. SEX
3. SOCIAL SECURITY NUMBER
4a. AGE-Last Birthday
4b. UNDER 1 YEAR
4c. UNDER 1 DAY
5. DATE OF BIRTH
6. BIRTHPLACE (City and State or Foreign Country)
(Mo/Day/Yr)
(Years)
Months
Days
Hours
Minutes
7a. RESIDENCE-STATE
7b. COUNTY
7c. CITY OR TOWN
7d. STREET AND NUMBER
7e. APT. NO.
7f. ZIP CODE
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7g. INSIDE CITY LIMITS?
Yes
No
8. EVER IN US ARMED FORCES?
9. MARITAL STATUS AT TIME OF DEATH
10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)
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Yes
No
Married
Married, but separated
Widowed
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Divorced
Never Married
Unknown
11. FATHER’S NAME (First, Middle, Last)
12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
13a. INFORMANT’S NAME
13b. RELATIONSHIP TO DECEDENT
13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)
14. PLACE OF DEATH (Check only one: see instructions)
IF DEATH OCCURRED IN A HOSPITAL:
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
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Inpatient
Emergency Room/Outpatient
Dead on Arrival
Hospice facility
Nursing home/Long term care facility
Decedent’s home
Other (Specify):
15. FACILITY NAME (If not institution, give street & number)
16. CITY OR TOWN , STATE, AND ZIP CODE
17. COUNTY OF DEATH
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18. METHOD OF DISPOSITION:
Burial
Cremation
19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
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Donation
Entombment
Removal from State
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Other (Specify):_____________________________
20. LOCATION-CITY, TOWN, AND STATE
21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT
23. LICENSE NUMBER (Of Licensee)
24. DATE PRONOUNCED DEAD (Mo/Day/Yr)
25. TIME PRONOUNCED DEAD
ITEMS 24-28 MUST BE COMPLETED BY PERSON
WHO PRONOUNCES OR CERTIFIES DEATH
26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)
27. LICENSE NUMBER
28. DATE SIGNED (Mo/Day/Yr)
29. ACTUAL OR PRESUMED DATE OF DEATH
30. ACTUAL OR PRESUMED TIME OF DEATH
31. WAS MEDICAL EXAMINER OR
(Mo/Day/Yr) (Spell Month)
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CORONER CONTACTED?
Yes
No
Approximate
CAUSE OF DEATH (See instructions and examples)
interval:
32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac
Onset to death
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional
lines if necessary.
IMMEDIATE CAUSE (Final
_____________
disease or condition --------->
a._____________________________________________________________________________________________________________
resulting in death)
Due to (or as a consequence of):
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Sequentially list conditions,
b._____________________________________________________________________________________________________________
if any, leading to the cause
Due to (or as a consequence of):
listed on line a. Enter the
_____________
c._____________________________________________________________________________________________________________
UNDERLYING CAUSE
(disease or injury that
Due to (or as a consequence of):
initiated the events resulting
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in death) LAST
d._____________________________________________________________________________________________________________
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
33. WAS AN AUTOPSY PERFORMED?
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Yes
No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
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COMPLETE THE CAUSE OF DEATH?
Yes
No
35.
DID TOBACCO USE CONTRIBUTE
36. IF FEMALE:
37. MANNER OF DEATH
TO DEATH?
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Not pregnant within past year
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Natural
Homicide
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Yes
Probably
Pregnant at time of death
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Accident
Pending Investigation
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Not pregnant, but pregnant within 42 days of death
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No
Unknown
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Suicide
Could not be determined
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Not pregnant, but pregnant 43 days to 1 year before death
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Unknown if pregnant within the past year
38. DATE OF INJURY
39. TIME OF INJURY
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
41. INJURY AT WORK?
(Mo/Day/Yr) (Spell Month)
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Yes
No
42. LOCATION OF INJURY:
State:
City or Town:
Street & Number:
Apartment No.:
Zip Code:
43. DESCRIBE HOW INJURY OCCURRED:
44. IF TRANSPORTATION INJURY, SPECIFY:
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Driver/Operator
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Passenger
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Pedestrian
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Other (Specify)
45. CERTIFIER (Check only one):
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Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.
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Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
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Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
Signature of certifier:_____________________________________________________________________________
46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 32)
47. TITLE OF CERTIFIER
48. LICENSE NUMBER
49. DATE CERTIFIED (Mo/Day/Yr)
50. FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)
51. DECEDENT’S EDUCATION-Check the box
52. DECEDENT OF HISPANIC ORIGIN? Check the box
53. DECEDENT’S RACE (Check one or more races to indicate what the
that best describes the highest degree or level of
that best describes whether the decedent is
decedent considered himself or herself to be)
school completed at the time of death.
Spanish/Hispanic/Latino. Check the “No” box if
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White
decedent is not Spanish/Hispanic/Latino.
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8th grade or less
Black or African American
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American Indian or Alaska Native
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9th - 12th grade; no diploma
(Name of the enrolled or principal tribe) _______________
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No, not Spanish/Hispanic/Latino
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Asian Indian
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High school graduate or GED completed
Chinese
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Filipino
Yes, Mexican, Mexican American, Chicano
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Some college credit, but no degree
Japanese
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Korean
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Yes, Puerto Rican
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Associate degree (e.g., AA, AS)
Vietnamese
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Other Asian (Specify)__________________________________________
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Yes, Cuban
Bachelor’s degree (e.g., BA, AB, BS)
Native Hawaiian
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Guamanian or Chamorro
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Master’s degree (e.g., MA, MS, MEng,
Samoan
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Yes, other Spanish/Hispanic/Latino
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MEd, MSW, MBA)
Other Pacific Islander (Specify)_________________________________
(Specify) __________________________
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Other (Specify)___________________________________________
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Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)
54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).
55. KIND OF BUSINESS/INDUSTRY
REV. 11/2003
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